AAIM Perspectives

BACKGROUND: Sabbaticals are an important feature of academia for faculty and their institutions. Whereas sabbaticals are common in institutions of higher learning, little is known about their role and utilization in US medical schools. This perspective piece examining sabbaticals in medical school faculty was undertaken at a time that well-being of health professionals was increasingly being recognized as a workforce health priority. METHODS: We surveyed associate deans at US medical schools in 2021 about faculty who had taken sabbaticals within the past 3 years, the parameters of the sabbaticals, and institutional policies and respondents’ predictions of future sabbatical use. RESULTS: A total of 53% of respondents reported any faculty had taken sabbaticals in the past 3 years (M = 6.27; Median = 3; range = 1-60). Institutions rated enhancing research as the most important objective, while recognizing other beneﬁts. Sabbaticals were more commonly taken by male, white, senior faculty PhDs. Details about sabbaticals, including eligibility, expectations, length, ﬁnancial support, and beneﬁts were reviewed. Most (54.8%) respondents expected no change in the number of faculty seeking sabbaticals. Nearly all anticipated the COVID-19 pandemic would not affect sabbatical policies. CONCLUSION: In contrast to other institutions of higher learning, sabbatical-taking by medical school faculty is rare. We explore factors that may contribute to this phenomenon (eg, the tripartite mission, faculty clinical responsibilities, culture of medicine, and student debt). Despite ﬁnancial and other barriers, a closer look at the beneﬁts of sabbaticals is warranted as a mechanism that may support faculty well-being, retention, and mental health. (cid:1)


INTRODUCTION
Physician wellness has been a topic of growing interest, especially as the mental health of health professionals has been adversely affected by the COVID-19 pandemic. 1 Interventions and strategies that promote wellness and mitigate burnout are increasingly sought after by employers of physicians. 2,3 Taking adequate time off and creating space for reflection are examples of interventions intended to promote faculty wellness.
Sabbaticals align well with this thrust. Sabbaticals in US higher education date back to their use as a hiring incentive at Harvard University in the 1800s. 4 Reuler 5 summarized benefits of sabbaticals for faculty and institutions: cross-pollination with faculty in other institutions, opportunities to focus on interests, learn new clinical and educational approaches, and experience "intellectual and professional renewal." 5 Additional benefits include faculty time away from academic duties to reflect on practice, participate in diverse activities, focus on research or service, boost morale and satisfaction, and improve performance. 4,6 Sabbaticals facilitate completion of scholarly activity that promotes advancement toward promotion and tenure. Sabbaticals can be granted to reward service and accomplishment (eg, research productivity). 4 From an institutional perspective, sabbaticals are a mechanism for promoting faculty development and retention. 7 Despite such benefits for faculty, the scant literature on US medical school faculty sabbaticals provides limited insights into role, frequency, and impact. One study 8 surveyed 70 faculty at 7 institutions who had taken sabbaticals and 15 who declined sabbaticals. Most viewed their sabbaticals favorably (80%) and were judged to have made scholarly contributions (75%). Decliners were concerned about the potentially disruptive impact on their unit, professional activities, potential advancement, financial or family constraints, or felt it was not necessary to achieve their objectives. The researchers also surveyed medical schools, finding in the 19 responding schools that only 2% to 16% of faculty took sabbaticals within a year of eligibility.
A survey of academic emergency medicine department chairs at 108 programs (90% response rate) revealed half their institutions had sabbatical programs; 39% were eligible to have their faculty participate, but only 13 (12%) programs had faculty participation. Of 2042 faculty in these programs, 40 (1.96%) had taken sabbaticals. They discussed requirements for and barriers to sabbaticals (eg, funding, graduate medical education regulations) and proposed strategies for surmounting them (eg, collaborations, seeking philanthropic and governmental funding, fellowships). 9 Other literature includes accounts addressing diverse issues. [10][11][12][13][14] For example, Reuler 5 offered recommendations for how to plan, prepare for, implement, and document sabbatical activities as well as addressed clinical matters and the impact on colleagues and academic or service units. A systematic review of professional sabbaticals concluded that good planning could overcome barriers to completing a sabbatical and that they are rare for pharmacists. 15,16 To address gaps in the literature during this period of greater attention to physician wellness and to develop a comprehensive perspective of medical school sabbaticals that might inform future practices, we invited faculty deans at all accredited US medical schools to complete a survey on sabbatical use.

Survey
We developed a survey to explore sabbatical policies and prevalence in US medical schools through an iterative process that yielded multiple choice and open-ended items. A draft version was piloted with 3 associate deans for faculty at medical schools to obtain feedback for refinement. The final version had 23 items addressing institutional characteristics, sabbatical policies/benefits, requirements, recent number of faculty taking recent sabbaticals, characteristics of faculty members who had taken sabbaticals, institutional objectives, and expectations. No data identifying individual schools or participants was obtained precluding follow-up with respondents. No incentives were offered to participants.

Survey Distribution and Analysis
We created a database of email addresses of associate deans for faculty at all US allopathic and osteopathic medical schools by searching websites for each institution. Solicitations were sent to 168 individuals with invitations to participate in the survey through a series of 6 emails from the research team and 1 email from a university-based associate dean of faculty affairs. Survey responses were collected via SurveyMonkey between November 30, 2020, and May 10, 2021. Data were downloaded from SurveyMonkey to Excel spreadsheets to develop descriptive statistics.

Survey Respondents and School Characteristics
Associate deans from 49 medical schools responded, a 29.2% response rate. Respondents were from public

PERSPECTIVES VIEWPOINTS
Burnout and threats to the well-being of physicians are high and were worsened by the COVID-19 pandemic. Sabbaticals offer a professional development opportunity away from teaching and clinical responsibilities that may enhance well-being, academic productivity, and career advancement. Sabbaticals are rarely taken by US medical school faculty. The majority of sabbaticals taken by medical school faculty were full professor PhDs.

Institutional Objectives of Sabbaticals
The objectives most important for institutions, as reported by respondents in Table 1, were to promote research and research collaborations beyond their institutions. Facilitating educational and clinical endeavors and following broader institutional sabbatical policies were the next most valued goals. Personnel matters including retention, promoting faculty wellness and mental health, preventing burnout, and enhancing recruitment were objectives, albeit not rated as highly.

Sabbatical Details
A total of 32 (65.3%) respondents' schools offered sabbaticals, and an additional 3 were considering instituting sabbaticals in the future. Of the 34 responses to an item about eligibility, most (32; 94.1%) reported tenure-track faculty were eligible, with fewer reporting eligibility for nontenure track (14; 41.2%), clinical (13;38.2%), research (13; 38.2%), and other (7; 20.6%) faculty. Schools varied in terms of the minimum years required on faculty, with 28 (93.4%) of 30 respondents' schools requiring at least 6 years on the faculty.
Institutions varied in terms of required outcomes; most (73.8%) required a summary of their experience. However, two-thirds (67.7%) did not track outcomes. Table 2 reveals schools had diverse policies regarding salary, based in part on the faculty revenue streams and length of the sabbatical. Partial salaries were common especially for longer sabbaticals. No salary support was available in some institutions, especially for shorter sabbaticals. No schools reported unique funding, such as dedicated budgetary allocations. Institutions maintained health benefits universally. Disability insurance was provided by most schools (71.4%); a quarter continued professional accounts (eg, for travel); and few (17.9%) maintained eligibility for bonus or incentives.

Demographics of Sabbatical Takers in Past 3
Years.

DISCUSSION
The number of medical school faculty who take sabbaticals relative to the total number of US medical school faculty is comparatively low. According to the Association of American Medical Colleges (AAMC) Faculty Roster in 2020, there were an estimated 184,481 faculty at US medical schools. If the rate of sabbatical taking is the same across responding and nonresponding   We attempted to gain perspective on this pattern by obtaining information about the prevalence of sabbatical-taking among faculty at US universities and colleges. Our queries of the American Association of University Professors and the Association of American Colleges & Universities failed to yield national data across higher education. Truly comprehensive national statistics are not available. However, the National Study of Postsecondary Faculty surveys of representative faculty revealed 260 faculty took sabbaticals in 1999 and 380 did in 2004. Such data suggest the use of sabbaticals by faculty outside of medical school is more extensive than within medical education and academic health care.
Overall, the data suggest that US medical school faculty rarely take sabbaticals and that policies vary among institutions. Analysis of who takes sabbaticals reveals that individual degree/discipline and rank appear to have a significant influence on their openness or ability to take sabbaticals. Early career faculty arguably may have the greatest need for protected time to write grants, undertake scholarly projects, and disseminate findings through publications to advance their careers and meet promotion and tenure criteria. In addition, the transition to midcareer is a juncture when faculty may potentially leave academic medicine for various reasons, including difficulties surmounting the professional hurdles while attending to personal and family matters. 17,18 However, the need to secure additional time relatively early in one's career to build a record of accomplishment is rarely met through the mechanism of sabbatical, which is consistent with broader findings in higher education. 4 Among medical school faculty, the majority taking sabbatical leave were PhD full professors, many of whom presumably have limited, if any, clinical obligations. This suggests that many factors (ie, patient care demands, culture of the workplace and/or of medicine, logistics, or lack of awareness of eligibility) may contribute to the reluctance of physician faculty or others who provide direct patient care to pursue sabbaticals. It is possible that the more missions to which one contributes (ie, education, research, and clinical service), the harder it may be for individuals to set aside time for sabbaticals. It is also possible, given the culture of medicine to be ambitious, perfectionistic, and hard charging, that junior faculty may be hesitant to take sabbaticals so as not to be perceived as lacking in such attributes that they perceive to be intrinsic to success in the medical school culture.
Given the trend for fewer medical school faculty to be on tenure tracks over time, 19 the connection between tenure decisions per se and the need for sabbaticals may be of decreasing importance. However, tenure eligibility and status may affect eligibility for sabbaticals; nontenured individuals at some schools are ineligible for sabbaticals.
Only 17% of respondents described their medical schools as encouraging faculty to take sabbaticals. Despite institutional messaging articulating the importance of professional development and faculty wellness, the realities of costs and the logistical and systems challenges associated with faculty absence may make administrators, institutions, and faculty ambivalent about them. Awareness of these institutional norms and attitudes regarding sabbaticals may play important, if subtle, roles in discouraging faculty from taking them. The survey did not focus on funding streams to support faculty sabbaticals. Further review of models, logistics, and sources of funding sabbaticals as well as the actual costs to institutions could clarify roles in contributing to current patterns of sabbatical taking and potentially could lead to creating more robust resources for this purpose.
The costs associated with funding sabbaticals have been controversial, with questions about affordability and sustainability 4 as well as recognition of the importance of investment in human capital as a critical feature of institutions. 20 Organizationally, consideration of costs balances those required to finance sabbaticals against those of potentially losing and then needing to replace faculty as well as the hard-to-measure financial and other impacts on the clinical, educational, and research programs related to revolving faculty. For example, it has been estimated that lost billings when physicians leave, and costs related to replace them (ie, recruitment, sign-on bonuses, and onboarding) range between $500,000 to more than $1 million per physician. 21 Potential loss of departing faculty member grants and potential future funds related to their intellectual property and entrepreneurial activities, as well as the loss of broader potential contributions as mentors and leaders and unique value in philanthropic endeavors, can also be costly for institutions. Collecting such data could allow for a more comprehensive assessment of the costs and benefits of sabbaticals.
At the individual faculty level, personal decisions about whether to pursue sabbaticals are likely influenced by the available salary support. It can presumably be a major financial disincentive to faculty taking sabbaticals, especially extended sabbaticals. Fewer than half (44%) of respondents indicated single semester/6-month leaves received full salary support. Even less support was available for longer sabbaticals. Given that younger faculty may still be paying off student loans, many faculty may be unable to afford taking sabbaticals even if doing so might confer diverse longterm benefits, such as providing a base for scholarly productivity, fostering professional development and positive attitudes, and promoting wellness. Given the mean medical school student debt of $241,600, 22 temporary salary reductions to pursue sabbaticals could be prohibitive for many faculty.
In this preliminary study, the major limitation was the response rate. It was sufficient to provide a baseline against which future studies of medical school sabbaticals can be compared. It is not known how representative respondent schools were of all US medical schools or how patterns might change over time. Limited response rates do not necessarily indicate sample bias. 23 Other than the time needed for respondent data review and survey completion, and the fact that the survey was conducted during the COVID-19 pandemic, we are not aware of factors affecting response rate or introducing bias. Variability in the comprehensiveness of responses to some items was also a limiting factor to the richness of the data set. It may reflect a limitation of how systematically medical schools track sabbaticals, confounding obtaining data for responding to some items.
Overall, despite their importance for faculty development and facilitating projects, sabbaticals of US medical school faculty are relatively uncommon and may be rarer than for other higher education faculty. In addition to their academic benefits, sabbaticals may have the potential to make a positive impact on faculty mental health, consistent with the fourth of the Quadruple Aims of health reform. 24 Implementation of initiatives to mitigate the effects of physician burnout 25,26 is warranted as these rates increase, 27 affecting physician mental health and well-being as well as patient care. 28 Within academic health care, burnout has been associated with physicians leaving institutions, 29 which is costly and disruptive. Given the limited impact of other strategies that have been studied to mitigate burnout in physicians, 3 further examination of the impact of sabbaticals on medical school faculty well-being is warranted. Lowering barriers, reassessing priority, and encouraging sabbatical-taking may make them impactful resources for more broadly supporting faculty, 30 which may enhance institutional capacity to fulfill their missions.
Our study did not address the effects of sabbaticals for medical school faculty. Better understanding of the effect of sabbaticals on the work of medical school faculty is warranted, particularly their role in supporting scholarly productivity as reported during the pandemic. 11 Mechanisms that facilitate scholarly productivity, including allotting more time, may enhance productivity and build long-term institutional loyalty and retention. 31 Additional research is needed into the effects of sabbaticals on medical school faculty.
Our data raises questions whether attitudes of faculty and administration toward sabbaticals are an underlying factor contributing to their modest utilization. Steps should be taken to change culture and increase awareness of sabbaticals as a viable, healthy option for academic medicine faculty. Salary support for sabbaticals can be enhanced and more standard provisions explored to minimize negative impacts of sabbaticals on faculty livelihoods. Various companies recognize the value to the company of financing sabbaticals. 32 Sabbaticals can provide focused time away from clinical duties sufficient to undertake and complete research and educational projects and participate in professional development. Further research is needed to understand better the impact of sabbaticals on the career trajectory of medical school faculty and their attitudes regarding sabbaticals.

CONCLUSION
The relevance of sabbaticals for medical school faculty deserves closer attention in today's high-pressure health care environment. Incorporating multiple approaches, including developing novel strategies, and harnessing the existing, albeit underused, mechanism of sabbatical, to promote faculty development and their academic contributions and mental health and wellbeing may mitigate the brunt of stresses inherent in academic health care. While such need has been especially evident during the COVID-19 pandemic, the needs extend more broadly: Developing sustainable means for supporting faculty success and well-being is critical to fulfilling the mission of academic health care. Higher priority is warranted to bolstering and retaining medical school faculty as they strive to provide frontline patient care, undertake essential research driving health care innovation, and educate future generations of physicians.